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Assessing pain in disorders of consciousness: the Nociception Coma Scale Dr C.Schnakers

Assessing pain in disorders of consciousness: the Nociception Coma Scale Dr C.Schnakers

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Assessing pain in disorders of consciousness: the Nociception Coma Scale Dr C.Schnakers

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  1. Assessing pain in disorders of consciousness: the Nociception Coma Scale Dr C.Schnakers Coma Science Group Cyclotron Research Centre and Departement of Neurology

  2. Pain Introduction| Methods | Results | Conclusion • « Pain is defined as an unpleasant sensory and emotional experience associated with real or potential tissue damage » • Pain experience is a subjective • experience mediated in part by beliefs or emotions www.comascience.org International association for the study of pain (IASP) Pain 1979

  3. Pain Scale b) Elderly Pain Assessment In Advanced Dementia Scale (PAINAD; Lane et al. 2003) Checklist of Nonverbal Pain Indicators (CNPI; Feldt 2000) Introduction| Methods | Results | Conclusion a) Newborns Neonatal Infant Pain Scale (NIPS; Lawrence et al. 1993) Faces, Legs, Activity, Cry, Consolability pain assessment tool (FLACC; Merkel et al. 1997) • Parameters • facial expression • cry • body movements • breathing patterns • state of arousal • consolability www.comascience.org

  4. Objective Introduction| Methods | Results | Conclusion To develop and validate a behavioural scale adapted for monitoring pain in patients with altered states of consciousness, the Nociception Coma Scale (NCS) www.comascience.org

  5. Nociception Coma Scale Introduction| Methods | Results | Conclusion www.comascience.org Schnakers et al, PAIN, 2010 Schnakers and Sazler, Cur Op Neurol, 2008; Schnakers et al, Encyclopedia of Consciousness, 2009

  6. Nociception Coma Scale Introduction| Methods | Results | Conclusion • Inclusion criteria: • age > 18 years • no administration of neuromuscular function blockers and no sedation within the 24 h of enrollment • presence of periods of eye opening • diagnosis of VS or MCS, based on the Coma Recovery Scale-Revised • Exclusion criteria: • documented history of prior brain injury • premorbid history of developmental, psychiatric or neurologic illness resulting in documented functional disability up to time of the injury • superior limb contusions, fractures or paralysis www.comascience.org Schnakers et al, PAIN, 2010 Schnakers and Sazler, Cur Op Neurol, 2008; Schnakers et al, Encyclopedia of Consciousness, 2009

  7. Participants Introduction| Methods | Results | Conclusion • 48 severely brain injured patients assessed with the • Coma Recovery Scale-Revised (Giacino et al, 2004) • - 28 in vegetative state • - 20 in minimally conscious state • mean age: 20-82y • time since onset: 15d-6y (31 acute and 17 chronic) • 17 traumatic www.comascience.org

  8. Procedure Introduction| Methods | Results | Conclusion • Pression administrated on the middle right and left • fingernail (5 sec) • using a standardized Newton meter (Force Dial; • www.wagnerinstruments.com) • Behavioural responses scored with the NCS and 4 pain • scales for non communicative patients: NIPS FLACC CNPI PAINAD Newborns Elderly www.comascience.org

  9. Concurrent validity Nociception Coma Scale Introduction| Methods | Results | Conclusion r * P <.05 Schnakers et al, PAIN, 2010 Schnakers and Sazler, Cur Op Neurol, 2008; Schnakers et al, Encyclopedia of Consciousness, 2009

  10. Clinical entities Introduction| Methods | Results | Conclusion Nociception Coma Scale MCS VS * P <.05 www.comascience.org Schnakers et al, PAIN, 2010 Schnakers and Sazler, Cur Op Neurol, 2008; Schnakers et al, Encyclopedia of Consciousness, 2009

  11. Inter-rater agreement Introduction| Methods | Results | Conclusion K .61 .93 .93 .73 .73 Total Motor Verbal Visual Facial Expression n=15 www.comascience.org Schnakers et al, PAIN, 2010 Schnakers and Sazler, Cur Op Neurol, 2008; Schnakers et al, Encyclopedia of Consciousness, 2009

  12. Sensitivity Introduction| Methods | Results | Conclusion * * * Baseline Tactile Noxious www.comascience.org Chatelle et al., in prep

  13. Introduction| Methods | Results | Conclusion the NCS may be an interesting tool to evaluate pain in severely brain injured patients with altered states of consciousness www.comascience.org

  14. Slides can be downloaded at www.comascience.org • M.Boly MD • D.Ledoux MD • C.Schnakers PhD • A.Vanhaudenhuyse PhD • M.A.Bruno PhD • O.Gosseries PhD • V.Cologan PhD • P.Boveroux MD • A.Demertzi PhD • the patients & families • C.Phillips PhD Ing • Q.Noirhomme PhD Ing • P.Maquet Pr • L.Puybasset Pr (France) • F.Perrin Dr (France) • F.Pellas MD (France) • A.Owen PhD (UK) • J.Giacino Dr (USA) • N.Schiff MD (USA) • H.Di Dr (Chine)

  15. Pain threshold Introduction| Methods | Results | Conclusion www.comascience.org Schnakers et al, PAIN, 2010 Schnakers and Sazler, Cur Op Neurol, 2008; Schnakers et al, Encyclopedia of Consciousness, 2009